John W. Ostrominski, MD: Prevalence of Cardiac-Renal-Metabolic Conditions in United States

John W. Ostrominski, MD

Credit: Brigham & Women's Hospital

A recent cross-sectional cohort study assessed temporal trends in cardiac, renal, and metabolic condition prevalence and overlap using National Health and Nutrition Examination Survey (NHANES) data between 1999-2002 and 2015-2020.¹

These data suggested cardiac, renal, and metabolic multimorbidity is prevalent and increasing among adults in the United States, with more than 1 in 4 adults having ≥1 cardiac-renal-metabolic condition.

Between 1999 and 2020, the proportion of US adults with multiple cardiac-renal-metabolic conditions increased significantly (5.3% to 8.0%; P < .001), as did the proportion having all 3 cardiac-renal metabolic conditions (0.7% to 1.5%; P < .001). The multimorbidity burden was particularly prevalent among individuals reporting older age, non-Hispanic Black race, or ethnicity, and adverse socioeconomic characteristics.

In a a recent interview with HCPLive, lead investigator John W. Ostrominski, MD, a clinical fellow at Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, elaborated further on these data and stressed the importance of cross-specialty collaboration to foster comprehensive management strategies. Ostrominski also touched on the recent American Heart Association (AHA) presidential advisory identifying strong connections between cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes (T2D), and obesity.²

HCPLive: Can you speak to the larger importance of understanding the prevalence and overlap of cardiac, renal, and metabolic conditions in the United States? How were these connections examined in this study?

Ostrominski: I would say that, conventionally, in clinical practice, and in research enterprises, we typically think about CVD, CKD, and T2D as isolated entities. But, it’s increasingly well-established that this is actually not the case. The overlap of these entities may be more of a rule, rather than an exception. There are several reasons for this.

I think, firstly, there are shared risk factors across the spectrum. But, one thing that I’ve certainly seen clinically, but I think we’ve seen epidemiologically is that there’s certainly a bidirectional or even multidirectional relationship shift between these major comorbidities or conditions. We know that, for instance, just looking at CKD, CKD is associated with an extraordinarily increased risk of incident heart failure.

But, heart failure itself can also beget worsening kidney function and CKD over time. The first thing that’s important to know is that this knowledge of these intersections, I think, is extremely important from a prevention perspective. We know that multiple therapies can reduce the risk of progression of these other comorbidities. The second is that diagnosis is also extremely important.

When in the context of an individual cardiac-renal-metabolic condition, or CKD condition, that patient or that population is at a higher risk of the additional kind of cardiac-renal-metabolic comorbidities. Adequate screening, for instance for microalbuminuria, or for diabetes, is absolutely critical to really maximize treatment opportunities.

The next element, again, is really treatment. It’s now in this era, I think especially and has been highlighted by major recent trials, including the FLOW trial, but also the trials that have examined finerenone and others. The multiple trials that are currently being conducted that are really focusing on specific intersections, clearly diagnosis is immensely important to really leverage these novel treatment opportunities.

Ultimately, we really wanted to better understand, in a contemporary population in the US, what was the degree of overlap between these 3 key types of conditions. We leverage a nationally representative serial cross-sectional study called ENHANCE. We looked at 2 key segments of that study, specifically a more contemporary cohort from 2015-2020. We essentially leveraged that cohort to establish the contemporary prevalence of cardiac-renal-metabolic conditions. We also looked back to 1999 to really try and adjudicate this key question of how these trends evolved over time, and if overlapping cardiac-renal-metabolic conditions are more prevalent now than prior.

HCPLive: Your results showed more than 1 in 4 US adults had ≥1 cardiac renal metabolic condition in the US and metabolic multimorbidity increased significantly from the 1999 cohort to the contemporary cohort. What are the key takeaways here? And when we consider these trends, where might these trends move toward in the future?

Ostrominski: I think the key point, the trends that we’ve seen only in the past 2 decades alone, are really quite striking. The prevalence of overlapping cardio-renal-metabolic conditions, specifically, any ≥2 of these conditions, has nearly doubled over the course of the past 2 decades alone. Although these are still relatively small numbers that we’re dealing with, those with a triple intersection – CVD, CKD, and T2D – have actually more than doubled over the course of the past 2 decades alone.

In the context of declining population level health, looking at those trends in cardiometabolic health and seeing how they’ve increased just over a recent time period. I think finding a forecast is always challenging, but I think this certainly suggests that in the context of greater population aging, and the increased prevalence of key risk factors for these conditions, these trends are likely to continue. That is not only cardio-renal-metabolic conditions themselves, but also the overlap of these cardio-renal-metabolic conditions, is again, probably to be increasingly the rule, rather than the exception.

HCPLive: The American Heart Association (AHA) released a presidential advisory defining cardiovascular-kidney-metabolic syndrome for the first time. For a lot of people now entering cardiology, this overlap will be the standard practice and not a changeover. From your perspective, what does this mean for the field?

Ostrominski: It was fantastic, actually, and very interesting and timely to see that the AHA really codified this perspective and this conceptual framework. Notably, one that really effectively is targeted at the antecedent condition of obesity and excess adiposity, which really highlights a thing where preventative strategies may ultimately go.

But, I think for practice now, I think those who are interested in entering the field, really across the spectrum too, I think the key message repeatedly is that we really have to rethink how we deliver care. And whether or not the historical siloed approaches, specifically, the cardiology, the primary care physician, the nephrologist or the diabetologist, or the endocrinologist, whether the siloed approach is really the better approach, or really a more integrative approach, maximizing the kind of combined intellect and skill of this group of physicians, actually works to maximize and improve outcomes.

The other key takeaway is to really maximize things at a population level, as certain key members of that group that I just mentioned, are relatively scarce across the US. Specifically, I think, to also improve the equity of care and also enhance across to these novel paradigms. I think it must, at least for me, and for other cardiologists who might work. I think cardiologists in general will need to embrace both the unique challenges, but also the unique opportunities of practicing a bit of weight management, a bit of endocrinology, and a bit of nephrology.

I think that’s going to, ideally, be the way that we will improve care, it serves to be a team effort. But, certainly, I think we have to broaden how we think about what our practice actually is.

References

1. _{Ostrominski JW, Arnold SV, Butler J, et al. Prevalence and Overlap of Cardiac, Renal, and Metabolic Conditions in US Adults, 1999-2020. JAMA Cardiol. Published online September 27, 2023. doi:10.1001/jamacardio.2023.3241}
2. _{Ndumele CE, Rangaswami J, Chow SL, et al. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association [published online ahead of print, 2023 Oct 9]. Circulation. 2023;10.1161/CIR.0000000000001184. doi:10.1161/CIR.0000000000001184}